NABH case study, GCS hospital, Ahmedabad

Name of the project

NABH Gap Analysis – Large healthcare organization

Name of the Hospital

GCS Medical College, Hospital & Research Centre, Ahmedabad

Owner of the hospital

Gujarat Cancer Society


Hospital Profile in Brief:

Gujarat cancer society was founded in 1961 and since then it has been providing care to the patient suffering from cancer at M.P.Shah Cancer Hospital, Civil Hospital Compound, Ahmedabad and Community Oncology Centre (COC), Vasna. Till date, lacs of patients have been diagnosed and treated.

In appreciation of the work undertaken by GCS, the Government of Gujarat has given them the responsibility and they have now developed a new medical college under Public Private Partnership. In the year 2009, GCS has established a 1000 bed GCS Medical College, Hospital which is 750 bed & Research Centre, with state-of-the art infrastructure and facilities


Project Summary:

The GAP analysis for GCS Medical College, Hospital & Research Centre, Ahmedabad was conducted from 9th till 13th April 2016. A visit to hospital premises and personal interviews of all categories of hospital staff was organized during this period. The purpose was to assess the functional areas of hospital services with a view of preparing the hospital for NABH Accreditation. The hospital staff including top management was highly motivated and inclined towards ensuring quality practices across the organization.

However, there were a few observations during assessment that could indicate the need for further intervention and enhancement, in order to meet the standards set by the NABH.

The hospital lacked a structured Quality Improvement and Continuous Monitoring department. There were a few regulatory & Statutory deficiencies due to which the hospital was advised to develop a proper mechanism to regularly update licenses/registrations/certifications. A tracker sheet was the best solution.

In terms of the Infrastructure, the hospital is really strong and has huge resources as far as space is concerned. However, there are a few concerns related to safety aspects of patients as well as employees. Emergency Codes as per guidelines were not defined yet. For example, Codes for Fire, Medical emergencies, External disasters etc. needed to be defined and displayed across the hospital.

Although there was a dedicated Infection Control Nurse, there was a major concern as the surveillance activities to capture and monitor Infection Prevention and control data was not being performed uniformly. The Bio-Medical Waste Management including storage, segregation and disposal area is one of the major concerns, although the same could be addressed with minimal hassles. Training needs were identified to be strengthened and conducted more frequently for the awareness of BMW Management.

Hospital also lacked proper Signage, another important NABH Criteria, needed re-designing to follow uniformity for the standardization of design, color coding, symbols, directional signs, etc as per the standard signage system.

Biomedical engineering also needed re-modulation in the form of more documentation and calibration and in-house preventive maintenance of the equipment.


Executive summary

The hospital was advised to have a fully-fledged Quality Department and the head of the department should be well versed with the NABH structure in order to carry out the Continuous Quality Improvement Program effectively throughout the organization.

The hospital, being a teaching institution, has appropriate mix of staff. However, the staff needed to implement changes and elevate the standard for delivery of Healthcare.

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